Advanced Endodontics is meant mainly for postgraduate students. It includes the most recent developments in the field of endodontics.

From diagnosis to periapical surgery, there have been significant changes, both in concept and equipment. Recently, tissue engineering has been used to revitalize dentin and pulp tissue.

In modern practice, proper diagnosis is the key for the success of endodontic treatment. This starts with a good relevant case history, clinical examination and diagnostic tests, which form an indispensable part of diagnostic system. The new methods of assessing pulp vitality like Laser Doppler flowmetry, Infrared thermographic imaging, pulse oxymetry, liquid crystal testing and Hughes probe eye camera are presently experimental and mainly research oriented and are expected to be clinical tests in the forthcoming days. Digital radiography and electronic apex locators have also revolutionized clinical endodontics. DNA and RNA based microbiological techniques to detect uncultivable microorganisms, i.e. Polymerase chain reaction and Microarray technology are used to identify and study a large array of genes. A relationship between clinical symptoms and inflammatory molecules has been demonstrated reporting the significance of substance ‘P’.

“Access is success” should always be borne in mind during endodontic treatment. A detailed knowledge of pulp chamber and root canal anatomy is required for success of endodontic treatment. There are various methods to determine exact working length including radiographic method and apex locators. Digital radiography has also revolutionized the clinical endodontics A film less technique commercially developed to reduce radiation exposure, is used to ‘digitalize’ the image that can be analyzed, measured and manipulated. Recently use of apex locators is considered to be the advanced method to determine the working length. First generation apex locators had disadvantages which have been overcome now by using third and fourth generation apex locators. These are reported to be very accurate in the determination of working length.

One of the key advancement in endodontic practice is operating microscope. It provides magnification and illumination and is useful for locating the canals after the access is made, and is necessary to address anatomical complexities and procedural complications associated with difficult cases. Enhanced vision, coaxial lighting and improved optics helps in identifying miniature canal openings, remnant pulp tissue and incipient fracture lines. The introduction of endoscopes at the turn of millennium involves using a fiberoptic probe to explore internal and external components of root canal aiding clinician in diagnosis and also to communicate and educate the patient.

The cleaning and shaping of the canal is one of the important preliminary requisite for endodontic treatment. There are various changes made in the endodontics instrument material and design. Nickel titanium (NiTi) files have become a mainstay in most endodontic procedures. Because of their property of shape memory and superelasticity, these files can be effectively used in curved canals for debridement. Varying the taper of the instrument leads to a more efficient preparation of root canal space. While biomechanical preparation can reduce the bacterial count significantly; mechanical debridement does not disinfect root canal system completely. Thus, a root canal irrigant is needed to aid in the debridement. Various techniques and irrigating solutions are currently used to attain disinfection. Recently MTAD has been introduced as a final rinse for disinfection of root canal system. This irrigant is able to remove the smear layer safely, and it is more effective disinfectant than NaOCl even against resistant bacteria such as Enterococcus faecalis.8

After proper cleaning and shaping and disinfection of root canal system, proper obturation of the canal is necessary to prevent reinfection. Different techniques of gutta-percha compaction have undergone various modifications in their insertion and compaction techniques. In older days torch or open flame was used to seal or melt the gutta-percha. This technique is now called “Flintstone” age endodontics. The system B and Touch-n-Heat allows a safer means to heat the gutta-percha. Delivery systems like Obutra II and solid core carriers like Thermafil and Simplifil have become a necessity in modern endodontic practice.

Ultrasonic devices have become essential tools for cleaning the isthmus after access preparation, assisting the removal of posts and separated instrument, root end preparation during surgical treatment of root canals, and searching for the calcified canals.

Lasers have various applications in endodontics such as measuring pulp vitality, preparing and disinfecting root canals and performing endodontic surgery. These devices offer a thin fiberoptic delivery system entering narrow root canals. Other applications of lasers include hemostasis, sterilization of root canals and smear layer and debris removal and even gutta-percha removal.

In spite of advancements in modern endodontic technology there are certain problems that may occur during or after treatment. Most common problems are broken instruments and perforations. Many kits have evolved for the removal of broken instruments from the canal like Masserian kit; Ruddles instrument removal system, etc., Management of perforations in the older times was done using calcium hydroxide, zinc oxide, and GIC during treatment or retreatment. Recently the advent of new material MTA (Mineral trioxide aggregate) has revolutionized endodontics. MTA has been used successfully in the repair of lateral root perforations and furcal perforations, vital pulp capping agent, apical plug in one visit apexification and as a root-end filling material and also as a coronal sealing material. A variety of new retrograde filling materials can be used which includes Super EBA, IRM, and Dentin bonding agents and most recently MTA and VERRM.

The science of endodontics has undergone significant changes which have resulted in improved treatment outcomes and an opportunity to preserve the natural dentition. These objectives can be achieved with less morbidity and more predictability. Compilation of more current clinical data that are based on procedures performed with more advanced techniques will provide a more accurate rate of healing after non-surgical and surgical endodontic therapy. The future holds the promise of continued growth of research knowledge and systematic reviews which will provide most valuable evidence connecting the patient, the clinician, the policy maker, the benefit purchaser and benefit provider in the decision-making process.

Endodontics is growing with rapidly changing treatment modalities in accordance with advancements in the technology leading to the precision in treatment outcome. No other branch in dentistry is changing at this rate. Procedures from access cavity preparation, Microscopes, Apex locators, Rotary instrument systems, Obturating systems and Surgical endodontics to tissue engineering have changed to an extent to appreciate the results clinically. The book in the form of Advanced Endodontics is the contribution of my vast experience to the profession.

In this regard I am extremely grateful to our Principal Dr C Bhasker Rao, who encouraged me throughout my career. I would like to thank Dr PNR Nair BVSc, DVM, PhD, Senior Scientist, Department of Oral and Structural Biology, Center of Dental and Oral Medicine, University of Zurich, Switzerland, who wrote the foreword of this book and has given me valuable suggestions.

My immense thanks to Dr Priya Horatti, Professor Department of Conservative and Endodontics for her contribution in this book. I would also like to thank all staff members of Conservative Department. It is my pleasure to acknowledge Dr Manjunatha RK postgraduate student who helped me in bringing out this book, and also all postgraduate students in the department of Conservative for their constant feedback and support.

It is my privilege to thank M/s Jaypee Brothers Medical Publishers (P) Ltd to bring this book for final shape.

I would like to thank Pujyashree Veerendra Heggade, President SDME Society for encouraging me to bring out this book. I would like to thank Mrs Suvarna SK, Computer Operator for helping in graphics and other book work.

Last but not the least, I would like to thank each and every person who has in some way or the other helped me.